Annual Wellness Visit - JF - Healthcare Common Procedure Coding System (HCPCS) G0438 and G0439 - Service Specific Targeted Review Final Findings

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs post-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings and closure of the case for HCPCS G0438-G0439. The results of this focused review are not a reflection on providers’ competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility’s compliance with the required documentation.

Summary of Findings

Since the initiation of the review, 434 claims were reviewed from December 23, 2020 through October 7, 2021. The breakdown of those findings are as follows:

  • 136 claims were allowed.
  • 14 claims were corrected for the following reasons:
    • Beneficiary history did not support that an initial Annual Wellness exam was completed for the beneficiary.
  • 284 claims were denied in full for the following reasons:
    • The requested records were not received.
    • The service was denied because the documentation submitted did not support all of the requirements of an annual wellness visit.
    • The service was denied because the documentation submitted did not support incident-to criteria.

The overall error rate since the initiation of this service specific targeted review is 61.89%. The error rate is calculated by dividing the dollar amount of charges billed in error (minus any confirmed under-billed charges) by the total amount of charges for services medically reviewed. If you disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice, although this will not affect the error rate of the post-payment review.

Education

Failure to Return Records

When the MAC requests documentation for review, it is the provider’s responsibility for the requested documentation to be received within 45 calendar days from the request. The MAC will not grant extensions to providers who need more time to comply with the request. Payment will not be made to any provider unless they have furnished the information as requested in order to determine the amounts due to the provider. Medicare will not pay for services unless they are deemed necessary and sufficient information is submitted that shows that services were provided. For payment, the services must be determined to be reasonable and necessary for the prevention or treatment of illness. Refer to Social Security Act 1815(a), 1833(e), 1862(a)(1)(A).

Annual Wellness Visit

Medicare covers an Annual Wellness Visit (AWV) for all beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period, and who have not had either an IPPE or an AWV within the past 12 months. Medicare pays for only one initial AWV per beneficiary per lifetime and one subsequent AWV per year thereafter.

The requirements of the annual wellness visits can be found in the Code of Federal Regulations (CFR), title 42, section 410.15.

Initial (G0438) and subsequent (G0439) AWV Components, at a minimum, must, address/update the following topics:

  • Demographic data
  • Self-assessment of health status
  • Psychosocial risks
  • Behavioral risks
  • ADLs, including but not limited to: dressing, bathing and walking
  • Instrumental ADLs, including but not limited to: shopping, housekeeping, managing own medications, and handling finances
  • Hearing impairment
  • Fall risk
  • Home safety

When billing an Evaluation and Management (E&M) code on the same day as the AWV:

  • The E&M must be significant and separately identifiable in the documentation
  • The E&M must medically necessary to treat the patient's illness or injury, or to improve the functioning of a malformed body member.

Incident To

Services may be covered under incident to when certain criteria is met. Auxiliary personal and students may perform services incident to under the supervision of a physician in certain settings. In an office setting, direct supervision indicates that physician is immediately available or in the office suite, however, is not required to be in the same room. Each occasion of service does not always need to be directly supervised. It could be considered as incident to when the service is being furnished during a course of treatment in which the physician has performed the initial service and the frequency of services reflects the active participation in the management of services.

Outside of the office setting (other than hospital or SNF), services may only be considered incident to if there is direct supervision of the physician. Incident to services are not covered under Medicare Part B for hospital patients or SNF patients. Incident to is covered when attending physician(s) render their services in a teaching setting to individual patients. The physician reviews the patient’s history and physical exams, personally examines the patient, confirms or revises the diagnosis, determine the course of treatment plan and assure that any supervision needed by interns or residents is furnished. The medical record must contain signed and countersigned notes by the physician that shows the physician personally reviewed the patient’s diagnosis, visited the patient at more critical times of the illness and discharged the patient. When surgical procedures are provided the medical record notes by interns, residents or nurses, which indicate the physician was physically present when the service was rendered, are sufficient. The teaching physician must be at least present during the key portion of the service rendered by a resident or intern. Refer to Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60.

Resources

For additional educational resources, please visit our Education and Outreach department.

Provider Action Required

Providers should review individual claim determinations.

To review individual claim comments via the Noridian Medicare Portal, complete the following steps:

  1. Log into Noridian Medicare Portal at https://www.noridianmedicareportal.com/
  2. Choose Claim Status from the menu bar.
  3. On the Claim Status Inquiry page:
    1. Fill in all Provider/Supplier Details.
    2. Select MEDB under Program drop down box
    3. Fill in all Beneficiary Details
    4. Fill in Claim Details.
  4. Click the Submit Inquiry button at the bottom of the form.
  5. On the Claim Status Results page
    1. Choose View Claim.
    2. On the right side of the page will the heading: Related Inquiries
    3. Choose Noridian Comments.
  6. Scroll down the page and under the Claim Status Line Details the comment will display.

Note: If documentation was sent late (>45 days from the date of the ADR), the claim may have been reopened by the examiner. These reviews are not currently available on the portal.

Initial documentation must be sent by fax, mail or esMD. Additional documentation requested can be submitted fax, mail or Noridian Medicare Portal.

Further provider action recommended includes:

  • Provide education regarding errors noted to applicable staff members.
  • Verify documentation supports medical necessity of the Annual Wellness Visit
  • Ensure ADR submissions are timely, complete, and include all documentation to support medical necessity and a valid physician order.
  • If records supporting the services on the claim are located at another facility, as the billing provider, your facility is responsible for obtaining those records for review.

Summary

Based on the error rate for this service specific probe this case is now closed and Noridian will no longer request documentation for this review. Noridian will continue to monitor data analysis and perform medical review for medical necessity and appropriate coding practices. If in the future, data indicates variances or high utilization, providers may be subject to a pre-payment or post-payment review.

If you would like to receive information regarding findings specific to your facility prior to the completion of the review, send an email to medicalreviewb@noridian.com. In order to facilitate the response, follow these instructions:

  • Complete the Subject line with the following information: Results request for HCPCS G0438-G0439 targeted review
  • In the body of the email, include the following elements:
    • Your name, title, and telephone number
    • The facility name
    • NPI Number
    • Short description of information you would like to receive
  • Indicate if you would like to receive results via phone call, fax or US Mail and include a fax number or mailing address as applicable.

Upon request receipt, Noridian Medical Review will respond as timely as possible.. Requests may take up to two weeks to be completed.

If you have any questions, contact the Provider Contact Center.

 

Last Updated Mon, 25 Oct 2021 15:23:15 +0000